2 3530 S. Val Vista Dr. #105 Gilbert, AZ Fax: IMPORTANT OFFICE POLICIES: Please Read and Sign this Form RELEASE OF MEDICAL INFORMATION I authorize OSPI Orthopedics to release and receive the medical records concerning myself/son/daughter to any physician, hospital, insurance carrier, or other agency involved in the care of the patient listed. RELEASE OF ELECTRONIC MEDICAL INFORMATION I authorize OSPI Orthopedics to release and receive, through software that meets or exceeds the Federal standard for encrypted electronic medical records concerning myself/son/daughter to/from any pharmacy, physician, hospital, insurance carrier, or agency involved in the care of the patient listed. ASSIGNMENT OF MEDICAL BENEFITS I request payment under the insurance policy of the card that was presented at the time of service be made directly to the provider listed on any claim for services furnished to myself/son/daughter during the effective period of this authorization. I authorize OSPI Orthopedics to release to the Social Security Administration, its intermediaries or carriers, any information required for this claim or any related Medicare or Medicaid claim. I authorize the release of any information necessary to determine these benefits or benefits payable for related services. PRIVACY PRACTICES AND HIPAA POLICY I have been offered a copy of OSPI Orthopedics Notice of Health Information Portability Accountability Act, and I understand that my health information will be protected by this act according to the written policy of OSPI Orthopedics. I understand that OSPI Orthopedics has the right to change this notice from time to time and that I may contact OSPI Orthopedics at any time to obtain a current copy. PAYMENT POLICY I understand that co-payments are to be collected at the time services are received. The office accepts cash, checks, Visa, American Express, and Master Card. All medical services provided are directly charged to the patient or responsible party. If a physician is contracted with my insurance carrier, the office will accept the negotiated rate for the charges billed. However, I will be responsible for any balance deemed patient responsibility/non-payable/non-covered by my insurance, and I will be billed accordingly. I will pay the full amount upon receipt of a statement, or I will make payment arrangements with the billing office. I agree to pay a $30.00 processing fee for any non-sufficient funds check, and I understand that I am responsible for form fees, $20.00 for the first page and $5 for each additional page, in the event I request forms from an outside party to be filled-out and signed by the physician. REFERRAL POLICY I understand that it is my responsibility to obtain a referral through my primary care physician s office if required by my insurance carrier. I understand that if I fail to procure the proper referral that the charges will become my responsibility. I HAVE READ, UNDERSTAND, AND AGREE TO ABIDE BY THE ABOVE RELEASE OF MEDICAL INFORMATION REGARDING TREATMENT, PAYMENT, AND OTHER OFFICE POLICIES. Patient/Guardian signature: Today s Date:

3 NAME (Last, First, M.I.): M F DOB: Age: HEIGHT: Weight: Right Handed Left Handed Amdidextrous REASON FOR VISIT: CURRENT CONDITION How long ago did this problem start? Days Weeks Months Years Is current problem a result from injury? No, please state how your symptoms began: Yes, (please circle one): Work Accident Car Accident Sport Other: Date of accident: Specify where and how it happened: Injury occurred from a: Lift Twist Fall Bend Pull Reach Hit by object Unknown Other: Comments: On a scale of 0-10 (10=worst), how sever is your pain? (circle) What is the quality of the pain? Sharp Dull Stabbing Throbbing Aching Burning The pain is now: Constant Comes and goes Does your pain wake you from sleep? Do you have the following? (Check all that supply): Bruising Joints giving away Locking/catching Numbness Swelling Tingling Weakness Painful popping Since the problem started, it is: Better Worse Same What makes your problem worse? (Check all that supply): Bending Exercise Kneeling Lifting Sitting Standing Squatting Twisting Walking Overhead activities Other: What is your single most painful activity? What makes your problem better? (Check all that apply): Heat Elevation Ice Rest Other: Have you had a prior problem with this same condition in the past? No Yes. If yes please describe:

Medical Registration Form (Page 1) Welcome to our Office: By completing this patient information form, you will help us to serve you more efficiently. Should you have any questions concerning our professional

Welcome to Avenstar Pain Specialists! Your completed intake paperwork helps our providers get to know you and your medical history. We rely on its accuracy and completeness to provide you with the best

Welcome! Please fill out this Patient Registration Personal: (Please Print Clearly, Sign ALL pages and be Complete) Last Name First Name Middle Street City State Zip Home Phone #: ( ) Work / Cell Phone

Notice of Privacy Practices Methods of Payments No Insurance? No problem! Claremore Eye Associates offers a discount for all non- insurance patients for their vision exam. We also accept all major credit

Medicare Insurance Registration Form (Page 1) Welcome to our Office: By completing this patient information form, you will help us to serve you more efficiently. Should you have any questions concerning

Dr. Sam Yoder, D.C. 101 Winston Way Ste B Campbellsville, KY 42718 Electronic Health Records Intake Form In compliance with requirements for the government EHR incentive program First Name: Address: Last

Personal Injury Questionnaire Patient Information Date Date of Birth Health Insurance Do you have a Flex Spending (FSA) or Health Savings (HSA) Account? Y N Patient Name First M Last What do you prefer

Dallas Neurosurgical and Spine Associates, P.A Patient Health History DOB: Date: Reason for your visit (Chief complaint): Past Medical History Please check corresponding box if you have ever had any of

GENERAL INFORMATION PATIENT REGISTRATION FORM All forms must be completed and signed prior to treatment. Account #: Patient Name: Address: Home Phone No: Cell Phone No: First Middle Last Work Phone No:

Accident / Injury Report Name Date Date of birth Date of accident Time of accident am / pm. Auto injury Were you: Driver Passenger Pedestrian Were you struck from: Behind Right Side Left Side Front Parked?

Welcome to Capital Endocrinology! We are happy to have you as a patient in our practice. Please take note of the following policies. Following these policies will help in making your visit as efficient

PATIENT INFORMATION - Please complete and/or verify all information and make changes as necessary. Today s : Are you here for an injury that is work-related? YES NO N/A Patient Name (First-Middle-Last)

We would like to welcome you as a patient and thank you for choosing Central Virginia Orthopaedics & Sports Medicine to provide your orthopaedic needs. It is our mission to provide you the highest level

Orthopedic Initial Questionnaire Name: Height: Date: Weight: In order to allow the therapist to have a better understanding of the nature of your injury and evaluate your condition fully, please complete

Orthopedic Initial Questionnaire Name: Date: Height: Weight: In order to allow the therapist to have a better understanding of the nature of your injury and evaluate your condition fully, please complete

WELCOME TO TRI-COUNTY EYE CLINIC Thank you for choosing Tri-County Eye Clinic as the provider for your eye care. You have an appointment at one of the following two locations: 15122 Dedeaux Road, Gulfport,

(mm/dd/yyyy): Have you been to Physicians Urgent Care before? Yes No Arrival Time: If yes, when? Is this a follow-up to a previous visit: Yes No PATIENT INFORMATION Patient s First Name: Middle Name: Last

Accident / Injury Report Name Date Date of birth Date of accident Time of accident am / pm. auto injury Were you: Driver Passenger Pedestrian Were you struck from: Behind Right Side Left Side Front Parked

Welcome! Thank you for choosing our practice for your eye care needs! Please fill out our new patient registration paperwork. So we may eliminate any potential waiting time, please fax the completed forms

REGISTRATION PAPERWORK CHECKLIST In order to make registration simple and quick, please use this checklist to make sure you have provided all necessary information and signatures. The process, including

MOTOR VEHICLE ACCIDENT QUESTIONNAIRE Thank you in advance for taking the time to complete this form, this will help us to better assess all of your pain concerns and provide you with the best treatment.

Medical Massage Client Intake Form Medical Massage Client Intake Form Client Name: Date: Please note: The more information you are able to provide, the better equipped our therapists will be to help you.

Calais Dermatology Associates Please present ALL insurance cards to the receptionist. If patient is a minor, and you are not the legal guardian, please ask receptionist for minor paperwork. Patient Information:

The more information we know about you and your family, the better medical care we can provide you. None of this information will be released to any person except with your written consent. LAST NAME FIRST

TOTAL PAIN RELIEF Dear Pain Patient, We would like to welcome you to our office. We strive to offer the best pain care with a multi-disciplinary approach. The registration and medical history forms must

Cancellation/No Show Policy If you are unable to keep your scheduled appointment we require a 24 hour advance notice. Failure to provide this notice will result in a $50.00 cancellation/no show fee. You

Address City State Zip Code Home Phone Cell Phone Cell Phone Carrier: Sprint Verizon AT&T Boost Preferred Contact: Home Cell Email Address Would you like to receive our newsletter and special offers and

PATIENT INFORMATION FILL OUT ALL ITEMS FAILURE TO COMPLETELY FILL OUT THIS FORM MAY RESULT IN YOU BEING BILLED IN FULL Patient Last Name: First: MI:. Address:. Date of Birth: Gender: M or F Marital Status:

What area hurts you the most? (Please choose one) When did this pain start? Neck Other: Back How did this pain start? How often do you experience this pain? Describe what this pain feels like. What makes

Welcome New Patients Thank you for choosing our practice for your care. The staff at Florence Neurosurgery & Spine would like to make your experience with our office a pleasurable one. In order to better